Article Search
검색
검색 팝업 닫기

Metrics

Help

  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
  • 3. Editorial Office
  • 4. Articles
  • 5. Instructions for Authors
  • 6. File Download (PDF version)
  • 7. Ethical Standards
  • 8. Peer Review

    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
    The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.

    The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.

Search

Search

Year

to

Article Type

Editorial

Split Viewer

A Shortened Fasting Time for Semifluid Diet Prior to Esophagogastroduodenoscopy: Achievement of Patient Comfort, Endoscopic Visibility, and Safety

Jae Yong Park

Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea

Correspondence to: Jae Yong Park
ORCID https://orcid.org/0000-0001-6114-8920
E-mail jay0park@cau.ac.kr

See “Four-Hour Fasting for Semifluids and 2-Hour Fasting for Water Improves the Patient Experience of Esophagogastroduodenoscopy: A Randomized Controlled Trial” by Meng-Xi Cai, et al. on page 382, Vol. 17, No. 3, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2023;17(3):347-348. https://doi.org/10.5009/gnl230133

Published online May 15, 2023, Published date May 15, 2023

Copyright © Gut and Liver.

Esophagogastroduodenoscopy (EGD) is a common procedure used to evaluate and treat various gastrointestinal conditions, which can be associated with patient anxiety and apprehension. The success and safety of this procedure rely on appropriate patient preparation, including adequate fasting prior to the procedure to ensure patient safety and mucosal visibility. The current standard practice for fasting before EGD is typically 6 to 8 hours for solid food.1,2 However, despite the evidence in favor of short preprocedural fasting durations, fasting from midnight is usually requested in actual clinical settings regardless of the scheduled time of the procedure. The total fasting duration in real world situation is therefore often much longer than the guideline, which can cause discomfort and even adverse events such as hypoglycemia.3 This practice needs to be reconsidered, since there are now growing interest on patient experience and demand for quality control in the fields of endoscopic procedures.

Recent studies have shown that shorter fasting times may be just as effective, but with fewer side effects. In this context, the study by Cai et al.,4 published in the current issue of Gut and Liver, adds to the growing body of evidence supporting shorter fasting times before EGD. This was a single-blind, randomized controlled study of 214 patients undergoing unsedated diagnostic EGD, aimed to investigate the efficacy of a modified 4-hour semifluid and 2-hour water (“4+2”) fasting protocol. Participants were randomized 1:1 to either the intervention or control group. The intervention group followed the “4+2” protocol, which involved ingesting 300 g of rice porridge 4 hours before the EGD appointment time and drinking <300 mL of clear water until 2 hours before the procedure. The control group followed the conventional protocol of fasting after midnight, with clear water allowed until 2 hours before the procedure. The participants’ comfort, procedural safety, and endoscopic visibility were evaluated.

Both the proportion of satisfaction (86.8% vs 63.9%, p=0.002) and the visual analog scale score (p<0.001) showed that participants’ comfort before EGD was considerably higher in the “4+2” protocol group. The percentage of satisfaction during EGD was also considerably increased (59.4% vs 45.4%, p=0.039) in this group. They were significantly more willing to (84.9% vs 75.0%, p=0.037) adopt the same fasting protocol for another EGD. Meanwhile, the fasting protocol had no impact on the overall visibility score (p=0.266), and all four gastric domains’ visibility scores showed no discernible variation either. All of the participants in the intervention group showed clean gastric mucosa, sometimes with little mucus only. The examination time was not significantly different between the two groups (308 seconds vs 311 seconds, p=0.522). Particularly, there were no documented adverse events, including aspiration, bleeding, infection, or perforation during the study.

The findings of this study have practical implications for clinical practice. Shorter fasting time before EGD may improve the patient experience by reducing the discomfort and inconvenience associated with prolonged fasting time. Moreover, it was safe and did not compromise the quality of the procedure. A 4-hour fasting period for semifluid and a 2-hour fasting period for water might be feasible and effective alternatives to the current standard practice of 8-hour fasting. These findings are consistent with previous studies that have shown similar results in terms of safety and efficacy of shorter fasting time before EGD. De Silva et al.5 found that a 1-hour water fast group experienced significantly less discomfort prior to EGD than a 6-hour fasting group without compromising safety and endoscopic visibility. Another study by Koeppe et al.6 showed that elective EGD after 2 hours fasting for clear liquids was more comfortable in terms of anxiety, general discomfort, hunger and weakness, and equally safe compared to conventional fasting.

The present study by Cai et al. has additional implication in that they demonstrated the feasibility of semifluid diet in the shortened fasting protocol. It is known that gastric emptying is mainly influenced by the consistency and components of the meal.7,8 The semifluid meal used in this study was rice porridge, only including carbohydrate and protein. This nutrient composition might be important, as high fat content might lead to the delay in gastric emptying.8

Interestingly, participants’ comfort was also significantly improved during the EGD with “4+2” protocol. Although the reason for this result was unclear, the stress level might have decreased due to the increased energy supply, along with possible reduction of negative experiences related to hunger, decreasing sensitivity to stimuli during EGD.

However, it is important to note that the results of this study should be interpreted with caution due to some limitations. Patients on proton pump inhibitors, having diabetes or prior history of upper gastrointestinal surgery, or undergoing therapeutic endoscopy were not included in the analysis. As we can easily anticipate, liberalizing fasting periods would not be suitable for all patients. More studies are needed to confirm these findings and assess their generalizability to different patient populations and clinical settings. Practitioners should consider the potential impact of patient factors, such as comorbidities and medication use, on the safety and efficacy of shorter fasting times prior to EGD.

Despite these limitations, this study highlights the need to reconsider the current standard practice of 8-hour fasting before EGD. Given that most patients undergoing non-emergent EGD are not in critical condition, the overall experience for these patients may be improved without compromising clinical outcomes by identifying lower risk individuals who can endure shorter fasting time. Furthermore, shorter fasting times may increase patient compliance with the procedure and improve the efficiency of endoscopy units.

Future studies are warranted, focusing on fasting time of different types and volumes of semifluid or other sub-populations of participants undergoing EGD to provide patient-oriented, individualized protocols for gastric preparation. For this purpose, initiatives such as development of proper diet formula and studies on risk factors for delayed gastric emptying would be necessary. Efforts should be made to achieve both goals of patient comfort and a safe and accurate examination.

No potential conflict of interest relevant to this article was reported.

  1. Bisschops R, Areia M, Coron E, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2016;48:843-864.
    Pubmed CrossRef
  2. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017;126:376-393.
    Pubmed CrossRef
  3. Sakulsaengprapha V, Daniel M, Cai J, Martinez DA, Mathews SC. Analysis of variation in pre-procedural fasting duration for common inpatient gastrointestinal procedures. Transl Gastroenterol Hepatol 2022;7:39.
    Pubmed KoreaMed CrossRef
  4. Cai MX, Gao Y, Li L, et al. Four-hour fasting for semifluids and 2-hour fasting for water improves the patient experience of esophagogastroduodenoscopy: a randomized controlled trial. Gut Liver 2023;17:382-388.
    Pubmed CrossRef
  5. De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ. One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol Hepatol 2009;24:1095-1097.
    Pubmed CrossRef
  6. Koeppe AT, Lubini M, Bonadeo NM, Moraes I Jr, Fornari F. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial. BMC Gastroenterol 2013;13:158.
    Pubmed KoreaMed CrossRef
  7. Collins PJ, Horowitz M, Maddox A, Myers JC, Chatterton BE. Effects of increasing solid component size of a mixed solid/liquid meal on solid and liquid gastric emptying. Am J Physiol 1996;271(4 Pt 1):G549-G554.
    Pubmed CrossRef
  8. Houghton LA, Mangnall YF, Read NW. Effect of incorporating fat into a liquid test meal on the relation between intragastric distribution and gastric emptying in human volunteers. Gut 1990;31:1226-1229.
    Pubmed KoreaMed CrossRef

Article

Editorial

Gut and Liver 2023; 17(3): 347-348

Published online May 15, 2023 https://doi.org/10.5009/gnl230133

Copyright © Gut and Liver.

A Shortened Fasting Time for Semifluid Diet Prior to Esophagogastroduodenoscopy: Achievement of Patient Comfort, Endoscopic Visibility, and Safety

Jae Yong Park

Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea

Correspondence to:Jae Yong Park
ORCID https://orcid.org/0000-0001-6114-8920
E-mail jay0park@cau.ac.kr

See “Four-Hour Fasting for Semifluids and 2-Hour Fasting for Water Improves the Patient Experience of Esophagogastroduodenoscopy: A Randomized Controlled Trial” by Meng-Xi Cai, et al. on page 382, Vol. 17, No. 3, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Esophagogastroduodenoscopy (EGD) is a common procedure used to evaluate and treat various gastrointestinal conditions, which can be associated with patient anxiety and apprehension. The success and safety of this procedure rely on appropriate patient preparation, including adequate fasting prior to the procedure to ensure patient safety and mucosal visibility. The current standard practice for fasting before EGD is typically 6 to 8 hours for solid food.1,2 However, despite the evidence in favor of short preprocedural fasting durations, fasting from midnight is usually requested in actual clinical settings regardless of the scheduled time of the procedure. The total fasting duration in real world situation is therefore often much longer than the guideline, which can cause discomfort and even adverse events such as hypoglycemia.3 This practice needs to be reconsidered, since there are now growing interest on patient experience and demand for quality control in the fields of endoscopic procedures.

Recent studies have shown that shorter fasting times may be just as effective, but with fewer side effects. In this context, the study by Cai et al.,4 published in the current issue of Gut and Liver, adds to the growing body of evidence supporting shorter fasting times before EGD. This was a single-blind, randomized controlled study of 214 patients undergoing unsedated diagnostic EGD, aimed to investigate the efficacy of a modified 4-hour semifluid and 2-hour water (“4+2”) fasting protocol. Participants were randomized 1:1 to either the intervention or control group. The intervention group followed the “4+2” protocol, which involved ingesting 300 g of rice porridge 4 hours before the EGD appointment time and drinking <300 mL of clear water until 2 hours before the procedure. The control group followed the conventional protocol of fasting after midnight, with clear water allowed until 2 hours before the procedure. The participants’ comfort, procedural safety, and endoscopic visibility were evaluated.

Both the proportion of satisfaction (86.8% vs 63.9%, p=0.002) and the visual analog scale score (p<0.001) showed that participants’ comfort before EGD was considerably higher in the “4+2” protocol group. The percentage of satisfaction during EGD was also considerably increased (59.4% vs 45.4%, p=0.039) in this group. They were significantly more willing to (84.9% vs 75.0%, p=0.037) adopt the same fasting protocol for another EGD. Meanwhile, the fasting protocol had no impact on the overall visibility score (p=0.266), and all four gastric domains’ visibility scores showed no discernible variation either. All of the participants in the intervention group showed clean gastric mucosa, sometimes with little mucus only. The examination time was not significantly different between the two groups (308 seconds vs 311 seconds, p=0.522). Particularly, there were no documented adverse events, including aspiration, bleeding, infection, or perforation during the study.

The findings of this study have practical implications for clinical practice. Shorter fasting time before EGD may improve the patient experience by reducing the discomfort and inconvenience associated with prolonged fasting time. Moreover, it was safe and did not compromise the quality of the procedure. A 4-hour fasting period for semifluid and a 2-hour fasting period for water might be feasible and effective alternatives to the current standard practice of 8-hour fasting. These findings are consistent with previous studies that have shown similar results in terms of safety and efficacy of shorter fasting time before EGD. De Silva et al.5 found that a 1-hour water fast group experienced significantly less discomfort prior to EGD than a 6-hour fasting group without compromising safety and endoscopic visibility. Another study by Koeppe et al.6 showed that elective EGD after 2 hours fasting for clear liquids was more comfortable in terms of anxiety, general discomfort, hunger and weakness, and equally safe compared to conventional fasting.

The present study by Cai et al. has additional implication in that they demonstrated the feasibility of semifluid diet in the shortened fasting protocol. It is known that gastric emptying is mainly influenced by the consistency and components of the meal.7,8 The semifluid meal used in this study was rice porridge, only including carbohydrate and protein. This nutrient composition might be important, as high fat content might lead to the delay in gastric emptying.8

Interestingly, participants’ comfort was also significantly improved during the EGD with “4+2” protocol. Although the reason for this result was unclear, the stress level might have decreased due to the increased energy supply, along with possible reduction of negative experiences related to hunger, decreasing sensitivity to stimuli during EGD.

However, it is important to note that the results of this study should be interpreted with caution due to some limitations. Patients on proton pump inhibitors, having diabetes or prior history of upper gastrointestinal surgery, or undergoing therapeutic endoscopy were not included in the analysis. As we can easily anticipate, liberalizing fasting periods would not be suitable for all patients. More studies are needed to confirm these findings and assess their generalizability to different patient populations and clinical settings. Practitioners should consider the potential impact of patient factors, such as comorbidities and medication use, on the safety and efficacy of shorter fasting times prior to EGD.

Despite these limitations, this study highlights the need to reconsider the current standard practice of 8-hour fasting before EGD. Given that most patients undergoing non-emergent EGD are not in critical condition, the overall experience for these patients may be improved without compromising clinical outcomes by identifying lower risk individuals who can endure shorter fasting time. Furthermore, shorter fasting times may increase patient compliance with the procedure and improve the efficiency of endoscopy units.

Future studies are warranted, focusing on fasting time of different types and volumes of semifluid or other sub-populations of participants undergoing EGD to provide patient-oriented, individualized protocols for gastric preparation. For this purpose, initiatives such as development of proper diet formula and studies on risk factors for delayed gastric emptying would be necessary. Efforts should be made to achieve both goals of patient comfort and a safe and accurate examination.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Bisschops R, Areia M, Coron E, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2016;48:843-864.
    Pubmed CrossRef
  2. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017;126:376-393.
    Pubmed CrossRef
  3. Sakulsaengprapha V, Daniel M, Cai J, Martinez DA, Mathews SC. Analysis of variation in pre-procedural fasting duration for common inpatient gastrointestinal procedures. Transl Gastroenterol Hepatol 2022;7:39.
    Pubmed KoreaMed CrossRef
  4. Cai MX, Gao Y, Li L, et al. Four-hour fasting for semifluids and 2-hour fasting for water improves the patient experience of esophagogastroduodenoscopy: a randomized controlled trial. Gut Liver 2023;17:382-388.
    Pubmed CrossRef
  5. De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ. One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol Hepatol 2009;24:1095-1097.
    Pubmed CrossRef
  6. Koeppe AT, Lubini M, Bonadeo NM, Moraes I Jr, Fornari F. Comfort, safety and quality of upper gastrointestinal endoscopy after 2 hours fasting: a randomized controlled trial. BMC Gastroenterol 2013;13:158.
    Pubmed KoreaMed CrossRef
  7. Collins PJ, Horowitz M, Maddox A, Myers JC, Chatterton BE. Effects of increasing solid component size of a mixed solid/liquid meal on solid and liquid gastric emptying. Am J Physiol 1996;271(4 Pt 1):G549-G554.
    Pubmed CrossRef
  8. Houghton LA, Mangnall YF, Read NW. Effect of incorporating fat into a liquid test meal on the relation between intragastric distribution and gastric emptying in human volunteers. Gut 1990;31:1226-1229.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.3
May, 2024

pISSN 1976-2283
eISSN 2005-1212

qrcode
qrcode

Share this article on :

  • line

Popular Keywords

Gut and LiverQR code Download
qr-code

Editorial Office